Provider Demographics
NPI:1194837278
Name:WYSONG, MARC JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:JOSEPH
Last Name:WYSONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-532-8584
Mailing Address - Fax:530-532-8433
Practice Address - Street 1:2809 OLIVE HIGHWAY
Practice Address - Street 2:#330
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966
Practice Address - Country:US
Practice Address - Phone:530-533-0774
Practice Address - Fax:530-533-3568
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q17919Medicare UPIN
0PA163190Medicare ID - Type Unspecified